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EBQ:PECARN Pediatric Head CT Rule

Complete Journal Club Article

Kuppermann N. et al. "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.". The Lancet. 2009. 374(9696):1160-1170.PubMedFull textPDF

Clinical Question

Can children be identified for low risk clinically-important traumatic brain injury and avoid Brain CT imaging.

Conclusion

This validated clinical decision rule provides a means of decreasing brain CT imaging in children with blunt head trauma with a sensitivity of 100% (<2years old) and 96.8% (>2yrs old) for intracranial injuries

Major Points

This rule was derived from the multicenter PECARN network with both a derivation and validation arm to detect clinically important traumatic brain (ciTBI) injury in children to age 18yrs old after blunt head trauma.

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)[2]

Study Design

Prospective cohort study in 25 emergency departments of the pediatric research network

Population

N=42,412

Derivation Arm: 33785

Validation Arm: 8627

Patient Demographics

Inclusion Criteria

Children presenting within 24 h of head trauma were eligible.

Exclusion Criteria

Children with trivial injury, ground-level falls, walking or running into stationary objects, no signs or symptoms of head trauma other than scalp abrasions and lacerations, penetrating trauma, brain tumours, pre-existing neurological disorders complicating assessment, or neuroimaging at an outside hospital before transfer.

Interventions

Patients were admitted to the hospital at physician discretion, research assistants identified records of admitted patients and emergency department CT results and ciTBIs. Telephone surveys were used to identify missed traumatic brain injuries from discharged patients between 7 and 90 days.

Missed ciTBI

2 Chidren were missed in the validation group for children aged 2 years and older, one with a subdural hematoma and the other with an occipital lobe contusion

Further Discussion

TBI and ciTBI was extremely rare in children and no one clinical factor in the high risk group could reliably predict a TBI. The high level of sensitivity of the rule must be weight agains the risk of over utilization of CT, exposure of ionizing radiation, and risk of missing a ciTBI.

Children with a GCS <14 are not included in this rule

At Denver Health, this rule was demonstrated to be superior to the CHALICE and CATCH rules[3]

The rarity of TBI in children was reinforced when analyzing those with isolated vomitting and no other positive factors on the decision rule[4]

Isolated Scalp Hematoma

For isolated scalp hematoma a sub analysis post-hoc analysis of the 2,998 patients with isolated scalp hematomas none required a neurosurgical intervention. The risk of clinically important traumatic brain injury overall was less than 1 in 200. [5]

Cost effectiveness

The application of the PECARN Head Trauma CT rule has shown to lead to beneficial outcomes and more cost-effective care[6]

Funding

The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, and US Department of Health and Human Services